MINNETONKA, MN/USA - MAY 29, 2016: UnitedHealthcare corporate headquarters exterior and sign. UnitedHealth Group Inc. is an American diversified managed health care company. Credit: wolterke/Adobe Stock;
In the wake of a four-year investigation of claims handling practices involving balance billing, North Carolina has fined UnitedHealthcare $3.4 million. In addition to paying the fine, the insurance company agreed to provide the state’s Department of Insurance with a corrective action plan to address violations uncovered during the investigation, as well as submit to future compliance examinations.
According to the North Carolina Department of Insurance, the investigation targeted UnitedHealthcare’s handling of member grievances and claims processes involving non-contracted or out-of-network providers and facilities for anesthesia services and emergency room services to see if the company was following its procedures to protect members from balance billing and complying with North Carolina law.
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Balance billing occurs when an out-of-network provider charges more than the insurer allows for an in-network service and tries to collect the excess cost from the member. The investigation found instances in which UnitedHealthcare did not follow its own procedures to negotiate with providers to hold the member harmless.
“Patients receiving emergency room services certainly don’t have the time or capacity to go through a checklist and make sure all providers attending them are in-network,” Mike Causey, the state’s insurance commissioner, said in a statement. “UnitedHealthcare’s practices potentially put unnecessary financial burdens on many North Carolinians. I am happy to see that UnitedHealthcare has agreed to take corrective action.”
While UnitedHealthcare accepted the final report and voluntary settlement agreement, it did not admit to the findings contained in the report — and, according to the state Department of Insurance, “expressly denied violating any statutes, rules, or regulations.”
The $3.4 million fine will be distributed for the benefit of public schools as required under Article IX, Section 7 of the North Carolina Constitution.
The state’s report claimed that UnitedHealthcare’s failure to have in-network anesthesiology and laboratory providers available at in-network facilities should not affect the member’s benefit level or cost-sharing responsibilities for covered services.
The report also found that when members filed grievances, UnitedHealthcare in many cases upheld its decision without any indication that efforts were made to intervene on behalf of the member to prevent them from being subjected to the difference between the amount billed and the companies’ allowed amount.
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